Sarcopenia as a Risk Factor for Complications Following Pedicle Subtraction Osteotomy.

STUDY DESIGN: Retrospective cohort. OBJECTIVE: The objective was to determine if sarcopenia is an independent risk factor for complications in adult spinal deformity (ASD) patients undergoing pedicle subtraction osteotomy (PSO) and define categories of complication risk by sarcopenia severity. SUMMARY OF BACKGROUND DATA: Sarcopenia is linked to morbidity and mortality in several orthopedic procedures. Data concerning sarcopenia in ASD surgery is limited, particularly with respect to complex techniques performed such as PSO. With the high surgical burden of PSOs, appropriate patient selection is critical for minimizing complications. METHODS: We identified 73 ASD patients with lumbar CT/MRI scans who underwent PSO with spinal fusion ≥5 levels at a tertiary care center from 2005 to 2014. Sarcopenia was assessed by the psoas-lumbar vertebral index (PLVI). Using stratum-specific likelihood ratio analysis, patients were separated into 3 sarcopenia groups by complication risk. The primary outcome measure was any 2-year complication. Secondary outcome measures included intraoperative blood loss and length of stay. RESULTS: The mean PLVI was 0.84±0.28, with 47% of patients having complications. Patients with a complication had a 27% lower PLVI on average than those without complications (0.76 vs. 0.91, P=0.021). Stratum-specific likelihood ratio analysis produced 3 complication categories: 32% complication rate for PLVI ≥ 0.81; 61% for PLVI 0.60-0.80; and 69% for PLVI < 0.60. Relative to patients with PLVI ≥ 0.81, those with PLVI 0.60-0.80 and PLVI < 0.60 had 3.2× and 4.3× greater odds of developing a complication (P<0.05). For individual complications, patients with PLVI < 1.0 had a significantly higher risk of proximal junctional kyphosis (34% vs. 0%, P=0.022), while patients with PLVI < 0.8 had a significantly higher risk of wound infection (12% vs. 0%, P=0.028) and dural tear (14% vs. 0%, P=0.019). There were no significant associations between sarcopenia, intraoperative blood loss, and length of stay. CONCLUSIONS: The increasing severity of sarcopenia is associated with a significantly and incrementally increased risk of complications following ASD surgery that require PSO. LEVEL OF EVIDENCE: Level III.

The Impact of the COVID-19 Pandemic on the Functionality of International Surgical Volunteer Organizations.

Background: Surgical volunteer organizations have been severely limited during the ongoing coronavirus disease pandemic. Our purpose was to identify obstacles to surgical volunteer organizations secondary to COVID-19 and their responses. Methods: Forty-one surgical volunteer organizations participated in a web-based survey (156 invited, 26% response rate). Respondents were separated into two groups: low donations surgical volunteer organizations (≤50% donations of previous year; n = 17) and high donations surgical volunteer organizations (≥75%; n = 24). Univariate analyses were used to compare the two cohorts. Results: Of responding surgical volunteer organizations, 34 (83%) were unable to maintain full functionality due to COVID-19; 27% of high donations vs. 0% of low donations surgical volunteer organizations (p = 0.02). The three leading obstacles were finances/donations (78%), fewer volunteers (38%), and inadequate personal protective equipment (30%). In response, 39% of surgical volunteer organizations developed novel E-volunteering opportunities. For support, 85% of surgical volunteer organizations suggested monetary donations, 78% promotion through social media platforms, and 54% donation of personal protective equipment. Conclusion: The majority of surgical volunteer organizations were unable to maintain full functionality due to stressors caused by COVID-19, including limitations on finances, volunteers, and personal protective equipment.

Applying to Fellowship During a Pandemic: Lessons Learned From the 2020-2021 Orthopaedic Spine Fellowship Application Cycle.

Introduction The COVID-19 pandemic resulted in a transition to a virtual format for all medical residency and fellowship application processes. Previous studies have discussed the successful implementation of virtual interviews, but a deep analysis of how the application process has changed for orthopedic surgery fellowship programs during the pandemic is lacking. The purpose of this study was to assess how COVID-19 impacted the orthopedic spine fellowship application and selection process. Methods A web-based survey was administered to the program directors of all 75 U.S. orthopedic surgery spine fellowship programs, which often can accept both orthopedic surgery and neurosurgery trained graduates. Questions focused on the changes from the 2019-2020 application cycle to the 2020-2021 cycle. We collected data on connecting with potential applicants, the general application process, and interviews offered by programs. Univariate analyses were used to compare data from the 2020-2021 cycle with the prior 2019-2020 cycle. Results Twenty-five of the 75 contacted program directors responded to our survey (33% response rate). The percentage of programs that offered virtual open houses/meet-and-greets increased from 20% in 2019-2020 to 52% in 2020-2021 (p=0.018). Social media use was unchanged (0.0% vs. 4.0%, p>0.05). Compared to the prior year, the number of interviews offered by programs increased by 1.5 (32.7 vs. 21.9 interviews, p=0.024). There were no significant differences in the numbers of applications received by programs, interview dates available, or separate interviews each candidate completed during an interview day (p>0.05 for all). The in-person interview was the most important factor in 2019-2020 for selecting applicants, whereas the virtual interview, letters of recommendation (LOR), and research were equally ranked as the most important factors in 2020-2021. Regarding interviews, 50% of respondents would "likely" consider virtual interviews as an option in addition to in-person interviews in the future, but most (55%) answered that it was "unlikely" that virtual interviews would entirely replace in-person interviews. Conclusion Spine fellowship programs were more likely to use virtual social events to recruit potential applicants, send out more interview invitations, and equally consider LOR and research with interview performance during an entirely virtual application cycle. Half of the program directors would consider offering virtual interviews as an option for future application cycles, which may help reduce costs associated with the process.

Spinal Epidural Hematoma Producing Neural Compression After Bilateral Rod Fractures in Failed Long-Construct Fusion: A Case Report.

CASE: A 75-year-old woman with remote history of T10-S1 spinal fusion with pelvic fixation presented with radicular back pain and numbness in the right lower extremity. Imaging showed bilateral rod fractures at L4-5 and a dorsal spinal epidural hematoma (SEH) with associated severe canal narrowing and cauda equina compression. The patient underwent bilateral L4-5 laminectomies, hematoma evacuation, reinforcement of multilevel nonunion, and implant replacement. Her symptoms resolved after the procedure. CONCLUSION: SEH is a rare complication that may occur secondary to failed spinal fusion and must be considered in the differential diagnosis of new or progressive neurological symptoms.

Biomechanical Comparison of Dual and Posterior Locking Plates in an Ex Vivo Comminuted Olecranon Fracture Model.

PURPOSE: Comminuted olecranon fractures are commonly fixed with posterior locking plates (PLPs). Though biomechanically validated, this method comes with risks of symptomatic implant prominence and wound breakdown. Dual locking plates (DLPs) placed on the medial and lateral surfaces of the olecranon theoretically avoid these risks and allow for fixation of proximal fracture fragments in multiple planes. A biomechanical comparison of DLP and PLP fixation would help to validate the use of DLPs in comminuted olecranon fractures. METHODS: Seven matched pairs of cadaveric upper extremities were evaluated with quantitative computed tomography scans to evaluate bone mineral density (BMD). Osteotomies simulating comminuted olecranon fractures (Mayo Type IIB) were created and the specimens were fixed either with variable angle PLPs or variable angle DLPs. The specimens were then cyclically loaded and loaded to failure. The ultimate strength, fracture displacement, and mechanism of failure were recorded and compared across groups. The correlation between BMD and ultimate strength was analyzed. RESULTS: The mean total BMD was 0.79 g/cm2 (SD, 0.14 g/cm2). No specimen failed during cyclic testing. Five of 7 PLP specimens and 5 of 7 DLP specimens failed by fracture through the proximal screws though in different planes (sagittal vs axial splits, respectively). The mean ultimate strengths of the PLP (1077 N [SD, 462 N]) and DLP (1241 N [SD, 506 N]) groups were similar. There was a linear relationship between ultimate strength and BMD (R2 = 0.33). CONCLUSION: Dual locking plates display biomechanical properties that suggest that they can be used in the fixation of comminuted olecranon fractures. Catastrophic failure of the fixation constructs occurs around stress risers at the proximal screws rather than due to displacement at the fracture itself. CLINICAL RELEVANCE: Dual locking plate constructs can be considered for use in the fixation of comminuted olecranon fractures.

International Orthopaedic Volunteer Opportunities in Low and Middle-Income Countries.

ABSTRACT: Globally, the burden of musculoskeletal conditions continues to rise, disproportionately affecting low and middle-income countries (LMICs). The ability to meet these orthopaedic surgical care demands remains a challenge. To help address these issues, many orthopaedic surgeons seek opportunities to provide humanitarian assistance to the populations in need. While many global orthopaedic initiatives are well-intentioned and can offer short-term benefits to the local communities, it is essential to emphasize training and the integration of local surgeon-leaders. The commitment to developing educational and investigative capacity, as well as fostering sustainable, mutually beneficial partnerships in low-resource settings, is critical. To this end, global health organizations, such as the Consortium of Orthopaedic Academic Traumatologists (COACT), work to promote and ensure the lasting sustainability of musculoskeletal trauma care worldwide. This article describes global orthopaedic efforts that can effectively address musculoskeletal care through an examination of 5 domains: clinical care, clinical research, surgical education, disaster response, and advocacy.

Adult Spinal Deformity Surgery Is Associated with Increased Productivity and Decreased Absenteeism From Work and School.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: We hypothesized that adult spinal deformity (ASD) surgery would be associated with improved work- and school-related productivity, as well as decreased rates of absenteeism. SUMMARY OF BACKGROUND DATA: ASD patients experience markedly decreased health-related quality of life along many dimensions. METHODS: Only patients eligible for 2-year follow-up were included, and those with a history of previous spinal fusion were excluded. The primary outcome measures in this study were Scoliosis Research Society-22r score (SRS-22r) questions 9 and 17. A repeated measures mixed linear regression was used to analyze responses over time among patients managed operatively (OP) versus nonoperatively (NON-OP). RESULTS: In total, 1188 patients were analyzed. 66.6% were managed operatively. At baseline, the mean percentage of activity at work/school was 56.4% (standard deviation [SD] 35.4%), and the mean days off from work/school over the past 90 days was 1.6 (SD 1.8). Patients undergoing ASD surgery exhibited an 18.1% absolute increase in work/school productivity at 2-year follow-up versus baseline (P < 0.0001), while no significant change was observed for the nonoperative cohort (P > 0.5). Similarly, the OP cohort experienced 1.1 fewer absent days over the past 90 days at 2 years versus baseline (P < 0.0001), while the NON-OP cohort showed no such difference (P > 0.3). These differences were largely preserved after stratifying by baseline employment status, age group, sagittal vertical axis (SVA), pelvic incidence minus lumbar lordosis (PI-LL), and deformity curve type. CONCLUSION: ASD patients managed operatively exhibited an average increase in work/school productivity of 18.1% and decreased absenteeism of 1.1 per 90 days at 2-year follow-up, while patients managed nonoperatively did not exhibit change from baseline. Given the age distribution of patients in this study, these findings should be interpreted as pertaining primarily to obligations at work or within the home. Further study of the direct and indirect economic benefits of ASD surgery to patients is warranted.Level of Evidence: 3.

Partial Delaminated Quadriceps Tendon Rupture: A Case Report.

CASE: We present a case of a 41-year-old male bodybuilder with a partial delaminated quadriceps tendon rupture after a traumatic injury. Partial quadriceps tendon tears are rare overall and usually are treated nonoperatively with conservative management depending on the patient's limitations. He was found to have an intact superficial quadriceps tendon with a partial thickness tear of the vastus intermedius and delamination of the undersurface quadriceps tendon precluding active knee extension. CONCLUSION: To our knowledge, there has never been a reported partial quadriceps tendon tear with delamination of the undersurface, causing a complete extensor mechanism failure necessitating operative repair.

Understanding Health Economics in Spine Surgery.

¼: The United States has faced substantial increases in health-care expenditure, with specifically large increases in spine surgery costs. ¼: Many different formulas are utilized to determine value in spine surgery, including cost- benefit analyses, cost-effectiveness analyses, and cost-utility analyses, with the overall determination of value being quality/cost. ¼: Quality often is calculated indirectly using either process measures or outcome measures and represents the potential benefit of a given intervention, usually over a specific time period to yield quality-adjusted life years. ¼: Costs are particularly difficult to calculate given the interhospital, regional, national, and global variability, as well as indirect costs of an intervention, and many different methods are utilized to estimate costs. ¼: Spine surgeons should be familiar with the elements that compose cost-effectiveness and their potential shortcomings in order for providers and health-care policy makers to identify the highest-quality studies and interventions that provide the greatest benefit to patients.

Global Volunteering in Orthopaedics: Availability and Implementation Considerations.

The World Health Organization describes traumatic injuries as a "neglected epidemic" in developing countries, accounting for more deaths annually than HIV/AIDS, malaria, and tuberculosis combined. Low- and middle-income countries rely on volunteer assistance to address the growing surgical disease burden of traumatic injuries. Efforts to increase the availability of international electives for orthopaedic trainees can help with the short-term need for surgical personnel abroad and facilitate sustainability through capacity building, maximizing long-term benefits for all parties. The volunteer invariably benefits from this cross-cultural experience with many citing improved skills in communication, clinical diagnostics, appreciation of equality and diversity, and cost-consciousness. A consolidated discussion regarding barriers and implementation strategies can assist interested individuals and institutions plan for future volunteering endeavors.

Patients Who Undergo Primary Lumbar Spine Fusion After Recent but Not Remote Total Hip Arthroplasty Are at Increased Risk for Complications, Revision Surgery, and Prolonged Opioid Use.

OBJECTIVE: To evaluate the effect of a recent history of total hip arthroplasty (THA) on primary lumbar spine fusion (LSF) for concurrent hip and spine disease. METHODS: A total of 98,242 patient records from the PearlDiver Database were evaluated and divided into 3 cohorts: 1) patients with a history of LSF alone, 2) patients with a history of LSF for newly diagnosed lumbar disease after having a remote THA> 2 years previously, and 3) patients with a history of LSF after having recent THA <2 years before LSF who initially presented with concurrent hip and lumbar spine disease and underwent THA before LSF. Postoperative outcomes were assessed with multivariable logistic regression to determine the effect of THA on outcomes after LSF with respect to postoperative complications, LSF revision rates, and opioid use. RESULTS: Patients who had LSF after a recent THA had increased risk of deep venous thrombosis (adjusted odds ratio [aOR], 1.39; P = 0.0191), neurologic complications (aOR, 1.81; P = 0.0459), prolonged opioid use (aOR, 1.22; P = 0.0032), and revision LSF (12.8%; P = 0.0004 vs. 9.9%; OR, 1.41; P < 0.0001; hazard ratio, 1.69; P < 0.0001). Patients who underwent LSF after a remote history of THA had no significant difference in DVT (4.2% vs. 2.6%, aOR, 1.31; P = 0.2190), neurologic complications (1.0% vs. 0.5%, aOR, 2.02; P = 0.1220), revision surgery (9.6% vs. 9.9%, aOR, 1.06; P = 0.7197), or prolonged opioid use (36.5% vs. 24.4%, aOR, 1.17; P = 0.1120). CONCLUSIONS: Patients who undergo LSF with a history of THA may be at increased risk of postoperative complications, revision LSF, and prolonged opioid use if their THA was performed for concurrent hip-spine disease in the recent past (<2 years).

Recognition and Management of Emergent Spinal Pathology Among First-Line Providers.

Spinal emergencies require prompt identification, management, and surgical referral (if needed) from first-line providers. Diagnostic delays from a failure to recognize emergency conditions can lead to adverse patient outcomes. The objective of this study was to understand the proficiency with which first-line providers can recognize and manage spinal conditions, particularly spinal emergencies. This was a cross-sectional analysis of 143 internal medicine, family medicine, emergency care, and neurology questionnaires collected at a single-site academic center. Participants were predominantly physicians (88.1%, n=126), with a smaller percentage of midlevel providers (11.9%, n=17). Only 35.0% (n=50) of respondents felt "very prepared" to handle spinal emergencies. Bivariate analyses revealed interdepartmental differences in clinical knowledge pertaining to the management of lumbar radiculopathy (P<.0001), epidural abscess (P=.0002), and cervical myelopathy (P<.0001). Following pairwise comparisons of interdepartmental differences, emergency medicine statistically outperformed internal medicine (P=.0007) and neurology (P<.0001) on initial management of lumbar radiculopathy, while also having markedly higher success in identifying and managing epidural abscess with respect to family medicine (P<.0001). The likelihood of appropriate initial treatment of cervical myelopathy was significantly higher for neurology than for emergency medicine (P<.0001). A minority of first-line providers reported being very prepared to handle spinal emergencies. Disparities exist between first-line provider specialties regarding clinical knowledge in managing and proficiently identifying emergent and nonemergent spinal conditions. Because appropriate handling of emergent spinal pathologies is essential to patient outcomes and optimal resource use, measures should be taken to further educate first-line providers regarding the spinal conditions they will be treating. [Orthopedics. 2020;43(4):e244-e250.].

Osteochondral Allograft Transplantation: Identifying the Biomechanical Impact of Using Shorter Grafts and Pulsatile Lavage on Graft Stability.

This study seeks to identify the ability of shorter osteochondral allografts (OCAs) to resist displacement/failure. Additionally, this study seeks to evaluate the effect of pulsatile lavage (PL) on the biomechanical stability of the OCA. Fifteen-millimeter diameter, human cadaveric, OCAs of 4, 7, and 10 mm in depth were harvested for comparison of resistance to compressive and tensile loads. For each group, seven specimens were subjected to tensile loads and three specimens subjected to compressive loads until failure (pullout or subsidence). An additional study group of 10 pulsatile-lavaged OCAs of 15 mm in diameter and 7 mm in depth were introduced for comparison to the original 7 mm depth OCA group. The average tensile forces for failure for the 4, 7, and 10 mm plugs were 23.74, 199.57, and 197.69 N, respectively (p = 1.5 × 10-5). After post hoc analysis of the tensile groups, significant differences in the mean tensile force to failure were appreciated between the 4 and 7 mm groups (p = 4.12 × 10-5) and the 4 and 10 mm groups (p = 1.78 × 10-5) but not between the 7 and 10 mm groups (p = 0.9601). There were no significant differences between the average tensile forces resulting in failure for the 7 mm and 7 mm PL groups (199.57 and 205.2 N, p = 0.90) or compressive forces to failure, respectively (733.6 and 656 N, p = 0.7062). For OCAs of 15 mm in diameter, a commonly used size in practice, plugs of 7 mm in depth showed comparable resistance to pull out and subsidence as 10 mm plugs and significantly better resistance to pull out than 4 mm grafts. PL of allografts prior to insertion did not take away from the structural integrity and stability of the plug.

Proximal junctional failure prevention in adult spinal deformity surgery utilizing interlaminar fixation constructs.

Proximal junctional kyphosis (PJK) is a common complication following fusion for Adult Spinal Deformity. PJK and proximal junctional failure (PJF) may lead to pain, neurological injury, reoperation, and increased healthcare costs. Efforts to prevent PJK and PJF have aimed to preserve or reconstruct the posterior spinal tension band and/or modifying instrumentation to allow for more gradual transitions in stiffness at the cranial end of long spinal constructs. We describe placement of an interlaminar fixation construct at the upper instrumented vertebra which may decrease PJK/PJF severity, and is placed with little additional operative time and minimal posterior soft tissue trauma.

Sarcopenia as a Risk Factor for Prosthetic Infection After Total Hip or Knee Arthroplasty.

BACKGROUND: Sarcopenia, an age-related loss of muscle mass and function, has been previously linked to an increased risk of morbidity, mortality, and infection after a variety of surgical procedures. This study is the first to evaluate the impact of the psoas-lumbar vertebral index (PLVI), a validated marker for central sarcopenia, on determining post-arthroplasty infection status. METHODS: This is a case-control, retrospective review of 30 patients with prosthetic joint infection (PJI) diagnosed by the Musculoskeletal Infection Society criteria compared to 69 control patients who underwent a total hip or knee arthroplasty. All patients had a recent computed tomography scan of the abdomen/pelvis to calculate the PLVI. PLVI was evaluated alongside age, gender, body mass index, Charlson Comorbidity Index, American Society of Anesthesiologists score, and smoking status to determine the predictive value for infection. RESULTS: Notably, the infected group had a large, significant difference in their average PLVI (0.736 vs 0.963, P < .001). The patient's PLVI was a predictor of infection status, with a higher PLVI being protective against infection (odds ratio [OR] 0.28, 95% confidence interval [CI] 0.109-0.715, P = .008). Additional predictors of infection status were higher American Society of Anesthesiologists score (OR 10.634, 95% CI 3.112-36.345, P < .001) and Charlson Comorbidity Index (OR 1.438, 95% CI 1.155-1.791, P = .001). Multivariate, binary logistic regression analysis confirmed that PLVI was a significant independent predictor of infection status (B = -0.685, P = .039). CONCLUSION: PLVI, a marker for central sarcopenia, was demonstrated to be a risk factor for PJI. Further research and consideration of sarcopenia as a screening and optimizable risk factor for total joint arthroplasty must be explored.

Spinal Emergencies in Primary Care Practice.

Atraumatic spinal emergencies often present a diagnostic and management dilemma for health care practitioners. Spinal epidural abscess, cauda equina syndrome, and spinal epidural hematoma are conditions that can insidiously present to outpatient medical offices, urgent care centers, and emergency departments. Unless a high level of clinical suspicion is maintained, these clinical entities may be initially misdiagnosed and mismanaged. Permanent neurologic sequela and even death can result if delays in appropriate treatment occur. A focused, critical review of 34 peer-reviewed articles was performed to identify current data about accurate diagnosis of spinal emergencies. This review highlights the key features of these 3 pathological entities with an emphasis on appropriate diagnostic strategy to intervene efficiently and minimize morbidity.

Diagnosis and Management of Hip Abductor Insufficiency.

Greater Trochanteric Pain Syndrome (GTPS) is a common cause of lateral hip pain, with an incidence of 1.8 per 1000 patients, most commonly occurring between the fourth and sixth decades of life. When GTPS fails to improve with conservative management, hip abductor insufficiency should be suspected. The diagnosis of hip abductor insufficiency is made by a combination of physical exam findings and imaging studies, with Magnetic Resonance Imaging (MRI) being the diagnostic study of choice. Initial conservative management consists of activity modification, physical therapy, non-steroidal anti-inflam- matories and corticosteroid injections. If conservative management fails, this may be suggestive of a hip abductor tear. Surgical intervention has been shown to provide excellent outcomes, and may be necessary if a tear is present. The purpose of this paper is to review and raise awareness of hip abductor insufficiency as an under- diagnosed and under-treated condition that can limit patient mobility and quality of life.